AND IMPROVEMENT GUIDE
improve compliance with JCAHO Environment of Care Standards
from JCAHO standards are © 2005 Joint Commission on Accreditation
of Healthcare Organizations. Any use of any or all of the Joint Commission
standards and elements of performance beyond this particular tool is
strictly forbidden without the written permission of the Joint Commission. Citations from JCAHO standards are © 2005 Joint Commission on Accreditation of Healthcare Organizations. Any use of any or all of the Joint Commission standards and elements of performance beyond this particular tool is strictly forbidden without the written permission of the Joint Commission. These pages do not reflect any changes in the standards made after 2005.
What is JCAHO?
The Joint Commission on the
Accreditation of Healthcare Organizations (JCAHO) sets
standards for healthcare organizations and issues accreditation to organizations
that meet those standards. JCAHO conducts periodic on-site surveys to
verify that "an accredited organization substantially complies with
Joint Commission standards and continuously makes efforts to improve the
care and services it provides."
What is this resource?
JCAHO standards address an organization’s
performance in key functional areas. Each standard is presented as a series
of "Elements of Performance" (EP) -- expectations that establish
the broad framework that JCAHO surveyors use to evaluate a facility's performance.
Some of the standards refer to environmental
issues. Many of the environmentally relevant Elements of Performance fall
under the "Environment of Care" (EC) standard, but others are included
in the Human Resources (HR) and Leadership (LD) standards.
This Guide relates each JCAHO Element
of Performance to specific federal regulations, to
help facilities be in compliance with both. The Guide also suggests steps that facilities
can take to encourage environmental performance improvements. A
comprehensive environmental program, including waste minimization
and pollution prevention initiatives, can not only
ensure compliance, but can also help reduce the costs of compliance.
How does it work?
Each page starts with the actual language of the JCAHO Element
of Performance, supplemented by a series of specific statements that refers
either to evidence that the organization is complying with the
standard, or to evidence that the organization is improving its
practices. Where appropriate, the guide provides links, tips and tools
that enumerate specific management practices, materials, regulatory requirements,
and facility infrastructure relevant to that EP.
Environmental issues are inherently complex, and the web
of regulations and practices that have evolved to deal with them can seem overwhelming
to the nonspecialist. To help make the information more user-friendly,
each page is organized using the following symbols to denote the type of information
available for each standard or Element of Performance:
||Evidence of Standards Compliance. These are
statements and direct links* to applicable federal environmental
and workplace regulations.
Evidence of Environmental Improvement. These
performance improvement initiatives go beyond what is absolutely required,
but typically ease the burden of compliance, often save money, and satisfy
JCAHO’s accreditation requirements.
A recommended set of Tools and Resources that may be particularly
helpful for those looking for additional information on specific topics,
sample policies, or guidance on how to deal with a particular problem.
*Links to the Code of Federal Regulations
(CFR) will automatically select the most recent version of the regulation
available from the Government Printing Office (GPO) website. (See note below).
Who is it for?
This information is offered:
- to JCAHO surveyors as a convenient reference for a complex
set of technical and regulatory issues
- to healthcare organizations as a means for maintaining
accreditation and improving your relations with and effects on the communities
Please contact us
This resource was created by Practice Greenhealth to supplement the guidance provided by the
JCAHO standards. We are very interested in your comments, and in finding
ways to improve this resource. Please direct your questions and suggestions
Proceed to the Table
of Contents to access the guidance for specific JCAHO
Elements of Performance.
Please note: Users may sometimes
experience delays in retrieving documents from the GPO website. Although
it is a very convenient resource, the GPO website has a potentially misleading
peculiarity: a document search that "times out" will return
the same error message as an erroneous citation. Clicking again on the
same link that produces the apparent error will often result in a successful
retrieval. If returning to the site at a less busy time is not a convenient
option for you, it may help to bypass the direct link and use the search
tree provided on the GPO website, selecting the appropriate Title, Part,
and Section for the most recent version available.
The following information will help you use the GPO search
tree. A standard citation format is used for all links to the Code of
Federal Regulations (CFR): if, for example, the citation reads "40
CFR 265.33", the reference is to Title 40, Part 265, Section 33. These
are the numbers you will need to use the search tree.
The first page of the search tree provides a table of all
the yearly revisions available for each Title. Ordinarily, you will want
the most recent revision, but it is not always available. You may find
it convenient to check the boxes corresponding to the two or three most recent
versions of the desired Title. Clicking "Continue" at the bottom
of that page will then provide a second page with a list of all the Parts for
each of the revisions checked. If the most recent revision for the desired
Part is not yet available on line, it will not appear as a live link in the
list. But if you have checked more than one box, then scrolling down
the second page will take you to the list of Parts for the next most recent
revision, and the desired Part will generally be found available as a live
link there. Clicking that link will take you to a third page, where you
can select the desired Section and bring up the text of the regulation.